Exporting a Student-Centered Curriculum: A Home Institution’s Perspective

Abstract

Numerous, mainly Anglo-Saxon, higher education institutions have agreements with foreign providers to deliver their curricula abroad. This trend is gradually making inroads into the medical domain, where foreign institutions undertake to offer their students learning experiences similar to those of the home institution. Not an easy feat, as the national health care contexts differ greatly between institutions. In a bid to export the curriculum, institutions risk compromising their financial resilience and reputation. This article presents an instrumental case study of a home institution’s perspective on the establishment of a cross-border student-centered curriculum partnership. It provides the reader with a practical discourse on dimensions that need to be bridged between home and host contexts, and on new working processes that need to be integrated within the home institution’s existing organizational structure. We describe the advantages and disadvantages based on our experiences with a centralized organizational approach, and advocate for a gradual move toward decentral interfaculty communities of practice.

Introduction

Many higher education institutions worldwide are forming cross-border curriculum partnerships (Lane, 2011), the essence of which is to transpose the “curriculum,” not students or faculty, from the location where it was developed (home) to the institution where it will be delivered (host; Knight, 2008). “Curriculum,” in this context, refers to the ensemble of content, assessment, and didactics. Although on one end, these international partnerships are mushrooming in areas such as languages, information and communication technology (ICT), business, and management (McNamara, 2013), on the other end, we find partnerships on the brink of collapse (Knight, 2008; Skidmore & Longbottom, 2011). Such occurrences are, to say the least, detrimental to the institutions’ reputation, financial liability, and efforts devoted by faculty. While the body of research into this novelty is expanding, its focus has hitherto stayed largely confined to partnerships’ motives and quality assurance processes (Kosmutzky & Putty, 2016; Lane, Brown, Christopher, & Pearcey, 2004; Waterval, Frambach, Driessen, & Scherpbier, 2014). Previous studies have indicated that, for partnerships to be sustainable, home and host institutions must bridge a wide range of differences, for example, in the areas of legislation, learning, and working environments and health care systems (Waterval, Frambach, Oudkerk Pool, Driessen, & Scherpbier, 2015). Other studies have reported that partnership sustainability is also contingent upon the formal set-up (i.e., the contract) of the partnership and intrapartnership relations, such as division of responsibilities and a suitable communication plan (Dobos, 2011; Heffernan & Poole, 2005). In this discourse, however, the institutional perspective on the educational, managerial, and strategic processes required to render these types of partnerships successful and sustainable has received scant attention, probably due to the sensitivity of the topic (Lane et al., 2004).

In a bid to address this gap, the present study describes, analyzes, and reflects on the experiences of a home institution that exported its medical student-centered curriculum to a host institution. Its purpose is to provide institutions who consider entering or who have entered a cross-border curriculum partnership with a deeper understanding of the possible challenges, approaches, and implications. By focusing primarily on the home institution’s perspective, we were able to probe more deeply into the issues faced by the home party. This does not alter the fact that a study into the host institution’s perspective would have yielded equally valuable insights and would complement this research, as the issues identified in the current study cannot be bridged without constructive actions and measures on either side (Knight & McNamara, 2015).

Method

Design and Setting

This study was set in the context of a medical undergraduate curriculum partnership between Maastricht University in the Netherlands (the home institution) and a newly established medical college in Saudi Arabia (the host institution). It spans a period of 7 years, from the first cohort of students entering their preparatory year until their graduation. We used an instrumental case study approach to address the aforementioned research objective. Essentially, such methodology uses a particular case to gain insight into an issue or phenomenon (Stake, 1995). In this article, we chose to explore Maastricht University’s experiences as a home institution (case) to illustrate and support our understanding of the process of transposing a medical curriculum (general phenomenon; Baxter & Jack, 2008). Ethical approval was obtained from the Netherlands Association for Medical Education Ethical Review Board (NVMO file number 629).

Research Team

The first, second, and third authors are employed full-time as international project officers by the home institution and jointly responsible for managing this partnership. They have detailed knowledge of the home institution’s curriculum, expertise in student-centered learning, and relevant work experience in the host country. It is through the lens of their experiences that this case study unfolded. In addition, the first author is pursuing a PhD on cross-border curriculum partnerships and has developed an overview of existing literature (Waterval et al., 2014; Waterval et al., 2015) that serves as a framework for reflection. The fifth and sixth authors were involved in the partnership’s set-up as deans of the home and host institution, respectively. The remaining two authors are medical education researchers specialized in internationalization, who are affiliated to the home institution but had no role in the partnership.

Data Collection and Analysis

In the first phase of the data collection and analysis process, the three project officers collected all project documentation to perform a chronological document analysis guided by the research objective. The output of these sessions, that stimulated the collective memory of the case, was consequently discussed in the entire research team. In the next stage, the management of the host institution verified whether the description and analysis resonated with their experiences.

On the basis of these findings and the literature, we developed a three-dimensional framework presenting the distances that both institutions needed to bridge, from the home institution’s standpoint, for the partnership to be successful. The next sections will elaborate on these dimensions, specifically “relational/cultural,” “geographical,” and “educational,” describing why they were an issue, how we tackled them, and what we learnt. Our findings will then be discussed in light of the existing literature. First, however, we will briefly expound on the partnership’s key characteristics and its inception.

Results

How It Started

In 2009, the founding dean of a then yet-to-be-established university in Saudi Arabia approached Maastricht University with the idea to initiate a curriculum partnership. He deliberately chose Maastricht University as an academic partner because of its reputation, global rankings, and experience with problem-based learning (PBL). The founding dean strongly favored student-centered education, which he believed would bolster the quality of graduates in his context (“Maastrichtse’ Faculteit in Saoedi-Arabië,” 2010). At first, Maastricht University was hesitant to accept the proposal due to its unfamiliarity with the type of partnership and the host country. Although these types of curriculum partnerships are quite common in Anglo-Saxon countries, they are rather uncharted territory for higher education institutions in the rest of Europe, especially in the field of medicine (McNamara, 2013). Mutual visits and background research, however, slowly but gradually helped to build trust and relationships between higher management. Eventually, the home institution decided to join in for various reasons, including the opportunity to bridge cultures that are at times in tension with each other, to export student-centered education to places where it is in demand, to earn a profit that could be invested in the quality of educational delivery at home, to “pilot” this form of internationalization, and to expand the university’s international network. Research found a similar myriad of reasons that persuade universities to entering these partnerships (Organisation for Economic Co-Operation and Development [OECD], 2004; Zhang, Kinser, & Shi, 2014).

By the end of 2009, both partners signed a contract governing the period from 2009-2020, in which they stipulated that the host institution should function independently according to the model of the home institution’s curriculum by September 2020. For this purpose, the host institution was to use Maastricht University’s 6-year undergraduate medical curriculum (content, didactics, and assessment) as the foundation for its own. The home institution committed itself to providing training to the management and teaching faculty of the host institution tasked with implementing the curriculum and adapting it to the local context. In addition, the home institution was to oversee the quality of the curriculum, for instance, during review visits. Although the ultimate object of the agreement was to offer host students a learning experience comparable with that of home students, the home institution is not entitled to award a Maastricht University degree upon graduation pursuant to restrictions imposed by Dutch law. As an alternative, the home institution issues a supplement to the host institution’s degree, testifying the quality of the program and its implementation signed by the highest authority of the home university. To sustain the partnership, the home institution created a project office, consisting of the three officers previously described who developed work processes, facilitated the exchange of materials, and had close links with decision makers. Although we were unaware of this at the time, the literature recommends a similar strategy of creating a small, dedicated team vested with powers to take prompt decisions so as to avoid time-consuming committee decision making (Castle & Kelly, 2004; Smith, 2009).

Bridging Relational and Cultural Distances

Institutional and personal relations at all levels can make or break a curriculum partnership (Dobos, 2011). This holds true not only for interfaculty relations between home and host institution but also for the relations within the home institution which must be strengthened to ensure and boost the commitment of home faculty (Shanahan & McParlane, 2005; Sidhu, 2009). Cultural differences between both contexts shine through in these relationships, and can complicate as well as enrich encounters. In our case, the cultural and religious distances between the Netherlands and Saudi Arabia were quite large and impacted relationships on many levels. Beyond that, the idea that the home institution, as a publicly funded research institution, embarked on this large-scale venture for reasons which were in part commercial created an air of suspicion among home institution faculty. This was reinforced by the fact that it was the first time educational services were used as substantial revenue stream. As a result, these faculty members did not list the collaboration as their number-one priority, a response identified as typical of home faculty in the literature (Shanahan & McParlane, 2005; Coleman, 2003). This situation posed a serious threat to the partnership, as our project office relied heavily on the support, input, and involvement of our colleagues for the transfer of knowledge and materials to the host institution.

To bridge relational distances and to foster a supportive culture among faculty members of the home institution, the project office regularly provided them with partnership updates by issuing newsletters and annual reports, and presenting at meetings. In addition, the project officers made sure to register and generously reward every effort, big or small, and to relieve home faculty as much as possible by answering all host institution’s questions not related to content, regarding structure, didactics, and logistics of the curriculum, for example. Most important of all measures, however, was the emphasis on personal encounters. Whenever the involvement of home institution faculty was requested, a project officer would meet these faculty members and brief them on the content and rationale of the collaboration as well as on cultural aspects. While in literature a more formal faculty induction program is advocated by some (Chapman & Pyvis, 2006; Seah & Edwards, 2006; Smith, 2009), we preferred a personal approach, which was highly valued and sometimes served as the gentle prod faculty needed to become involved and reduce their anxiety. In the end, cultural distance constituted no real impediment to participation for the vast majority of home faculty, both male and female. On the contrary, considering the open attitude of faculty members toward new experiences, this cultural distance induced many of them to become involved in the collaboration.

The relational and cultural distance between partners existed not only on faculty level but also on the level of higher and project management. As noted in literature, these relations are the “grease” of the partnership and eventually determine success or failure to a large extent (Dobos, 2011; Dunn & Wallace, 2006; Heffernan & Poole, 2005; Smith, 2009). It was with ups and downs that we learned about this. We soon realized that creating strong links meant “doing the little things” on multiple levels, for example, between faculty, project officers, and higher management, as emphasized by Heffernan and Poole (2005). At the level of project management for instance, the project office adopted the policy to respond to questions within 24 hr also during weekend. We noticed how much this was valued by our counterparts and how this prevented frustrations and misunderstandings especially as our contract only listed main issues, while governing an 11-year period. Therefore, good relationships and communication were indispensable to continuously negotiate details of the collaboration.

Despite these efforts, it was inevitable that relational and cultural distances manifested themselves variously in online and offline communication, which could easily have triggered stereotyping as other studies have warned for (Dobos, 2011; Dunn & Wallace, 2006; Seah & Edwards, 2006). A survey among faculty of transnational programs revealed the magnitude of this issue, with over 50% of respondents reporting communication styles as a challenge in the delivery of cross-border education (Keay, May, & O’Mahony, 2014). As cultural context and communication strongly influence one another, Keay et al. champion the intensification of efforts to ensure that information is exchanged and that both parties understand its meaning. Our way of dealing with this potential threat was to involve project officers in most interactions between home and host faculty, especially in the initial phase, to explain the background of questions and act, if necessary, as intermediary between faculty members. This strategy appeared beneficial as the number of incidents stayed limited to isolated events—for example, an individual teacher’s disappointment with an unmet agreement—that did not influence the overall partnership relations.

Bridging Geographical Distances

Besides relational distances, the geographical distance between the two partners further complicated overseas implementation of the curriculum. Not only did differences in time and space between the institutions affect the partnership, but also the physical transfer of learning materials, the pivot of the partnership, proved to hold several unforeseen pitfalls. For an extensive account of challenges similar to the ones we faced, although derived from different settings, we refer to the work by Lane (2011) and Lim (2010). At the start, we realized that transfer of the home curriculum, which comprised a variegated range of educational sessions and materials owing to its multidisciplinary, integrated, and competency-based nature, required an equal amount of different approaches. Subsequently, we discovered that it was difficult to lend transparency to all aspects of the curriculum, as much content appeared to be hidden with faculty members running their sessions based on implicit and tacit knowledge and experience.

Another bottleneck presented itself when the project office undertook its first mission to gather and prepare all formal documentation intended to explicitly guide the implementation process: Various learning tools that were embedded in the home curriculum, such as software programs and access to the electronic or home-based library, were actually owned by third parties and had not been identified upfront. We therefore had to make separate arrangements with each individual third-party owner, leading to differences in the availability of these learning tools between home and host institution, especially in the first years. Other case studies by Castle and Kelly (2004) and Wilson (2002) have reported similar challenges.

Furthermore, preventing a smooth transfer of materials was the fact that both institutions relied on different e-learning environments, which made direct transfer impossible. We learnt that for the transfer and synchronization of the curriculum to run smoothly, both sides need expertise on how to structure the learning environment as well as a basic understanding of how to use the educational materials.

A final hurdle was the realization that the transfer of materials, rather than being an isolated activity, was a continuous process, as the curriculum was updated and adjusted on a yearly basis. With home and host curricula running simultaneously and parts of assessment materials being identical, this synchronization needed to be on time and accurate. In their case studies, Dobos (2011), Dunworth (2008), and Lim (2010) also warned that the scope of continuous synchronization is easily underestimated, an oversight that can have major repercussions. In our experience, synchronizing the curriculum so far has been no easy feat, not only in terms of content but also logistically, with national holidays, working days, and weekends differing across both institutions. Therefore, we found that mutual investment of time and effort in long-term advance planning and coordination, at least 1 year ahead, was crucial and prevented surprises that were most unexpected and their associated consternation.

Bridging Educational Distances

Physical transfer of curriculum materials did not automatically result in transfer of the curriculum, that is, its local fit, acceptance, and understanding of curriculum content, didactics, and assessment by the host institution’s stakeholders, such as students, faculty, management, parents, hospitals, and patients. The different educational traditions on both sides created an educational distance between home and host contexts that needed to be bridged. Although host faculty were generally dedicated and eager to learn, they had a background in teacher-centered lecturing, which approach was scarcely reconcilable with the student-centered educational concept that represented the backbone of the home institution’s curriculum. Other institutions have reported similar experiences (McBurnie & Ziguras, 2007; Ziguras, 2001), while some authors have signaled potential problems in implementing student-centered curricula developed in Western contexts in other settings (Frambach, Driessen, Chan, & van der Vleuten, 2012). Yet other authors have denounced such ventures altogether for their ingrained and often unquestioned cultural assumptions (Bleakley, Brice, & Bligh, 2008). Aligning the educational cultures of home and host institution has indeed been a challenge, to which we responded by seeking to explicate assumptions on both sides. Fostering student-centered education was an explicit goal of our agreement, which we sought to achieve by paying a number of training visits and a review visit each year, based on a mutual needs analysis initiated by the host institution. We also launched a University Teaching Qualification program at the host institution: a longitudinal certified training program aimed to train host faculty in their various teaching roles, to equip them with a theoretical foundation for learning, and to establish a culture of peer review. We are in the process of developing a medical education department at the host institution, which may eventually assume responsibility for faculty development that is currently resting with the home institution. However, the challenge to align both different traditions remains a constant, especially when viewed in the light of literature findings emphasizing that training does not automatically cause faculty to gain a deep understanding and apply a new educational philosophy (Heffernan & Poole, 2005; Lim, 2010; Shams & Huisman, 2012).

Another explicit objective of the agreement was to adapt home curriculum content as much as possible to the host context. Hodges, Maniate, Martimianakis, Alsuwaidan, and Segouin (2009) have warned against the inherent risk of imported curricula not responding to the host country’s health care needs. Although in the first 2 years the host program ran entirely on home curriculum content, it gradually came to incorporate local adaptations, such as the introduction of host-designed elective courses. In the third year, contextualization of the curriculum occurred almost automatically, as the program was largely patient-based, with host students being exposed to the local health care setting and prevailing diseases.

Differences in educational contexts became especially pronounced with the introduction of home-invented assessment methods into the host setting. Our experience is echoed in the work by other researchers who point out that the potential differences in assessment cultures and national legislation influence the delivery of the curriculum (Eldridge & Cranston, 2009; McBurnie & Ziguras, 2007; Miliszewska & Sztendur, 2011). In our case, the host institution had to comply with the national accreditation standards for education and assessment, which place a strong emphasis on summative knowledge testing. This contrasted considerably with our aforementioned student-centered philosophy that favored the provision of formative feedback to students rather than marks only. Despite initial efforts to implement and explain the rationale of the home institution’s assessment program, we soon realized it was a bridge too far. Therefore, the host institution, in consultation with the home institution, eventually developed its own assessment program, which included additional items, tutorial assessments, different weightings of exam components, and more formal assessment moments in the clinical phase. This strategy gave the host institution more control over its assessment and is illustrative of the pragmatic stance we adopted: one of being open to and influenced by each other, which has also been promoted in literature (Djerasimovic, 2014). As a corollary, we now have two curricula that are far from identical, yet comparable in terms of their essential features and intended learning outcomes. In the long run, it will be interesting to investigate the impact of the more intensive and summative assessment system on host students’ learning behaviors, considering the strong relation between assessment and learning (Schuwirth & Van der Vleuten, 2011).

Discussion

In the previous section, we have recounted the challenges faced and the working procedures adopted by a home institution that established a student-centered medical curriculum partnership. Looking back in hindsight on the last 7 years, we can say that the partnership has developed in accordance with the initial agreements and to the satisfaction of both partners. Although distances seemed daunting at face value, we managed to overcome the main obstacles and to have two comparable student-centered medical curricula run simultaneously in two different countries. Transfer of student-centered principles appeared viable, indeed, as evident from the appreciation host students repeatedly expressed during review visits. Other studies have reported similar experiences (Jippes & Majoor, 2008; Khoo, 2003; Koh, Khoo, Wong, & Koh, 2008). Moreover, equivalent standardized summative knowledge tests administered in the first years yielded comparable student results in both curricula, while the first batch of host graduates passed their national licensing exam, the gateway to medical practice, and specialty training. These are strong positives ascribable to both partners, which bolster confidence in the robustness of the implementation. On a more individual level, many home faculty members reported that their visits to the host country and meetings with students and staff had positively changed their beliefs and ideas about the host country’s culture.

Although we successfully managed the said distances, they keep requiring our constant attention as the influx of new faculty on both sides may spark new cultural miscommunications and differences in expectations. In addition, as the home institution’s curriculum is regularly updated, efforts must continue to be channeled into maintaining close relationships between faculty and project office. For these reasons, we shifted the focus of our faculty development strategy away from individual teachers’ behaviors toward organizational policies, structure, and culture: a persistent effort that will determine the sustainability of the curriculum in the long run. Now that the first batch of students has graduated and the partnership is maturing, we are entering a new phase, one in which flow of ideas and information between home and host institution will be transformed from a unilateral direction (until now the host institution relied heavily on input and guidance from the home institution) toward a more bilateral flow (in which host faculty provide feedback and suggestions for curriculum improvement).

The present case study provides an example of a partnership in which management is centralized in one project office tasked with the initiation, channeling, and management of nearly all flows of communication and materials between partners. Preconditions for the success of this type of management included having a core team of officers well versed in the context of both institutions with good connections with key faculty to ensure the parallel and timely delivery of curricula. This construct has helped the home institution to overcome the aforementioned “distances,” by accelerating the decision-making process, addressing cultural differences, being easily accessible to host faculty, reducing workload for home faculty, and serving as a reference point for home faculty who are unfamiliar with the new work processes. However, the project office may risk becoming an isolated entity within the organization. Being heavily reliant on the central project office, home faculty members might be less inclined to take ownership of the partnership. As a result, the flow of information from home to host institution may stay largely confined to updates, home decisions, and home products (British Council & DAAD, 2014).

A decentralized alternative to the centralized-management approach is to establish direct linkages and communication lines between faculty in all echelons of the home and host institutions. Such approach requires a substantial adaptation of home faculty’s roles and responsibilities. Tasks and responsibilities such as organizing online meetings with geographically separated faculty, for instance, must become institutionalized in the faculty role descriptions. The management will need not only a strategy to coordinate these numerous meetings but also a “disintegration strategy” or plan B when partners digress because of diverging interests. Inevitably, such joint enterprises will tax the cultural competences of the faculty members involved and increase the risk of miscommunications and misunderstandings compared with a partnership based on a mediating project office. In the long run, however, the decentralized approach which enhances collaboration and joint development between members of home and host faculty could facilitate the implementation of updates and adaptations on both sides. Keay et al. (2014) argued that such bilateral interfaculty communities of practice that develop educational products together could improve the quality of curriculum delivery. By creating a stronger network, they provide opportunities for research collaboration and other positive spin-offs. They also redress the imbalance of power between home and host faculty in terms of knowledge and feelings of curriculum ownership and offer a platform for the host faculty to make suggestions for improvement of the delivery and quality of the home institution’s curriculum.

Which management approach would best suit such partnerships depends on several conditions, such as the availability of faculty, financial endowment, long-term strategic objectives, and the prevailing cultural and geographical distances. The two management approaches we have outlined can be considered as two extremes on a continuum. Depending on the type of partnership and its stage of maturity, we encourage a move along this continuum: from a more centralized approach, which increases the likelihood of the partnership being rooted in the home organization, toward a more decentralized approach to reap the educational benefits of an equal relationship between faculty members of both institutions. We welcome further studies into these flexible approaches to manage curriculum partnerships.

This case study has a number of limitations. First, several members of the research team assumed the dual role of researcher and informant, which may have led us to give an overly optimistic presentation of the partnership, its challenges, and outcomes. To minimize this bias, we included two authors who were outsiders to the curriculum partnership and explicitly addressed the possibility of bias during our reflections and discussions with all authors. Notwithstanding these considerations, the inclusion of project officers as authors allowed us to collect rich data and detailed insights into the challenges and the strategies to overcome them.

A second more important limitation is that this case study only reflects one side of the partnership. We strongly encourage host institutions to conduct comparable research on managerial processes and strategies to disclose their views. Together with the present study, such reports will offer a comprehensive picture of this revolutionary trend in the internationalization of education, medical, or otherwise.